CurrentAvMedPolicy N/A

PA Gastric Acid Suppression Drugs (Prior Authorization / Step-Edit)

This document governs prior authorization and step-edit requirements for selected gastric acid suppression drugs (including dexlansoprazole, omeprazole/sodium bicarbonate, and vonoprazan) for AvMed members; it affects prescribers and pharmacies seeking coverage.

Policy Summary

PayerAvMed

PolicyPA Gastric Acid Suppression Drugs (Prior Authorization / Step-Edit)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a signed Pharmacy Prior Authorization/Step-Edit Request form with required documentation showing four 30‑day trials of generic PPIs.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4generic PPIs required

30trial duration (days)

3document sections

3listed drugs

Coverage Criteria

Approval criteria

Covered when ALL of the following are met

Form and documentation requirements: Prescriber must sign and complete the PA/Step-Edit form with required member and prescriber information, dosing, diagnosis, and supporting documentation (labs, diagnostics, chart notes).

Incomplete or missing documentation may delay or result in denial; prescriber signature must be hand-signed (preprinted stamps not valid).

Step therapy requirement: Member has tried and failed four (4) generic proton pump inhibitors (PPIs) from the listed agents, each trial lasting 30 days, prior to approval of the requested drug.4 drugs; 30 days each

Previous therapies will be verified via pharmacy paid claims or submitted chart notes.

Use of drug samples to initiate therapy does not meet step-edit/preauthorization criteria. This policy requires documented trials of the specified generic proton pump inhibitors (PPIs) rather than relying on samples to satisfy step-therapy requirements; approvals will be based on verification of prior therapy via pharmacy paid claims or submitted chart notes.

Policy Summary

PayerAvMed

PolicyPA Gastric Acid Suppression Drugs (Prior Authorization / Step-Edit)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a signed Pharmacy Prior Authorization/Step-Edit Request form with required documentation showing four 30‑day trials of generic PPIs.

SourceLink

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Provider Submission & Documentation Requirements

Prior Authorization

Submission & Signature Requirement

Prior authorization must be submitted using the Pharmacy Prior Authorization/Step-Edit Request form and must include the prescribing physician’s handwritten signature and printed name (preprinted signature stamps are not valid). Fax the completed form to 1-305-671-0200. Incomplete, incorrect, or illegible information (including missing phone/fax numbers) may delay processing or result in denial.

Form must include prescriber signature and printed name (preprinted stamps not valid)
Fax completed form to 1-305-671-0200
Office staff may complete other fields but prescriber must sign

Step Therapy

Step-Edit Prior Therapy Requirement

Approval requires documentation that the member has tried and failed four (4) generic proton pump inhibitors (PPIs). Each prior drug must have been tried for a 30-day trial before approval of the requested step-edit drug.

Required 30-day trials of four generic PPIs: esomeprazole, lansoprazole, omeprazole, pantoprazole, or rabeprazole (see list below)
Use of samples to initiate therapy does not satisfy step-edit requirements
Previous therapies may be verified via pharmacy paid claims or submitted chart notes

Documentation Required

Required Form Fields & Supporting Documentation

The PA form must include member identifiers, prescriber name, prescriber NPI, office contact, phone and fax numbers, prescriber signature and date, drug name/form/strength, dosing schedule, length of therapy, diagnosis and ICD code (if applicable), weight (if applicable) with date, and supporting clinical documentation (lab results, diagnostics, chart notes) to substantiate any checked clinical criteria. Failure to provide documentation supporting each checked criterion may lead to denial.

Member name and AvMed number, date of birth
Prescriber name, NPI, signature, and date
Office contact name, phone and fax number
Drug name/form/strength, dosing schedule, length of therapy, diagnosis, ICD code if applicable, weight and date obtained
Attach lab results, diagnostics, and chart notes to support each checked clinical criterion

Denial Risk

Form Completeness & Missing Documentation Risk

If the PA form is incomplete, incorrect, or illegible, or if required supporting documentation is not provided for checked clinical criteria, the authorization process may be delayed or the request may be denied.

Incomplete/incorrect/illegible information may delay processing or cause denial
Missing documentation to support checked criteria may result in denial

Step Therapy

Required Step Therapy — Specific Agents

Member must have tried and failed four (4) generic PPIs with each prior drug tried for 30 days before approval of the requested step-edit drug. Eligible generic PPIs include: esomeprazole (20 or 40 mg), lansoprazole (15 or 30 mg), omeprazole (10, 20 or 40 mg), pantoprazole (20 or 40 mg), and rabeprazole (20 mg). Not all drugs may be covered under every plan; if a drug is non-formulary, documentation of medical necessity is required.

esomeprazole 20 or 40 mg
lansoprazole 15 or 30 mg
omeprazole 10, 20 or 40 mg
pantoprazole 20 or 40 mg
rabeprazole 20 mg
If non-formulary for the plan, provide medical necessity documentation

Required prior trials	Dose/Strength(s)	Trial duration
Esomeprazole	20 mg or 40 mg	30 days
Lansoprazole	15 mg or 30 mg	30 days
Omeprazole	10 mg, 20 mg or 40 mg	30 days
Pantoprazole	20 mg or 40 mg	30 days
Rabeprazole	20 mg	30 days

OpenPayer

PA Gastric Acid Suppression Drugs (Prior Authorization / Step-Edit)

Coverage Criteria

Coding and Prior Trial Duration

Provider Submission & Documentation Requirements

Step Therapy Requirements